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Midazolam

Short-acting benzodiazepine · Anxiolytic/Sedative

Also known as Dormicum, Versed, Midazolam Hydrochloride

START
Procedural: 0.5–2 mg IV slow, titrate; status epilepticus 10 mg IM/buccal/intranasal
TYPICAL MAX
Titrate to effect; reduce in elderly/hepatic/renal — flumazenil available
STOP IF
Respiratory depression/apnoea, severe hypotension, paradoxical reaction
WATCH
Continuous SpO2/respiration + BP, resuscitation/flumazenil available, cumulative dose in ICU
CDSCO approvedSchedule XATC N05CD08
Dose laddermg/d
0.5start2titrate5max10ceiling
Renal dose adjustmenteGFR mL/min/1.73m²
FULLUsual titration30REDUCEReduce dose — active glucuronide acc…≥90

KDIGO 2024 + manufacturer label

Pharmacokineticsplasma · t hours
3minONSET5minPEAK2.5ht½45minDURATION
ONSET
3min · IV onset (~2 min)
PEAK
5min · IV peak (~5 min)
t½
2.5h · plasma t½
DURATION
45min · single-dose effect
EXCRETION
Hepatic CYP3A4; renal metabolites (active glucuronide)
route + CYP
INTERACTIONS
12 major
incl. contraindicated
PREGNANCY
Avoid in pregnancy unless benefit outweighs risk; neonatal sedation/withdrawal/floppy infant if used near delivery
FDA category + note
Top interactionssee all 12 →
  • ItraconazoleContraindicatedDatabaseKimi deep-research + Cla
  • Sodium OxybateContraindicatedDatabaseKimi deep-research + Cla
  • AzolesSevereTextbookHarrison 22e · p1742
  • MethylnaltrexoneSevereTextbookG&G 14e
Available in India

38 branded formulations. Look up specific brands in the Drugs workspace.

Mechanism

Positive allosteric modulator at the GABA-A receptor benzodiazepine site, enhancing GABA-mediated chloride influx → sedation, anxiolysis, amnesia, anticonvulsant and muscle-relaxant effects; rapid onset, short duration.

Indications

Procedural and ICU sedationInduction/co-induction of anaesthesia; premedicationStatus epilepticus / acute repetitive seizures (IV/IM/buccal/intranasal)Palliative sedation

Dosing

Adult
Procedural sedation: 0.5–2 mg IV slow, titrate (total often 2.5–5 mg). Status epilepticus: 10 mg IM/buccal/intranasal (or 0.2 mg/kg). ICU infusion 0.02–0.1 mg/kg/h titrated.
Pediatric
Buccal/intranasal 0.2–0.5 mg/kg for seizures; procedural per weight (specialist).
Renal adjustment
Active metabolite (1-OH-midazolam glucuronide) accumulates in renal failure — reduce dose/prolonged sedation risk.
Hepatic adjustment
Reduce dose (decreased clearance, prolonged effect).
Geriatric
Markedly reduce dose and titrate slowly (enhanced/prolonged sedation, falls).
Max dose
Titrated to effect; status epilepticus single 10 mg IM/buccal (adult)

Pharmacokinetics

Onset
IV 1–3 min; IM ~15 min; buccal/intranasal ~10 min
Peak effect
IV ~3–5 min
Duration
~30–60 min (single dose; longer with infusion/organ impairment)
Half-life
~1.5–3 h (prolonged in elderly/renal/hepatic impairment, obesity)
Bioavailability
IM ~90%; oral ~36% (first-pass); buccal ~75%
Protein binding
~96%
Metabolism
Hepatic CYP3A4 → active 1-hydroxymidazolam (glucuronidated)
Excretion
Renal (metabolites; active glucuronide accumulates in renal failure)

Contraindications

  • Acute narrow-angle glaucoma
  • Severe respiratory insufficiency / acute respiratory depression (without ventilatory support)
  • Hypersensitivity to benzodiazepines
  • Concomitant strong CYP3A4 inhibitors with oral midazolam (e.g. HIV protease inhibitors)

Side effects

Common
Sedation/drowsinessAnterograde amnesiaHypotensionRespiratory depression (dose/route-dependent)Injection-site reaction
Serious
  • Respiratory depression/arrest and apnoea (esp. with opioids)
  • Severe hypotension
  • Paradoxical agitation (children/elderly)
  • Dependence/withdrawal with prolonged ICU use

Pregnancy & lactation

Pregnancy

Avoid in pregnancy unless benefit outweighs risk; neonatal sedation/withdrawal/floppy infant if used near delivery

Lactation

Single procedural dose generally acceptable with brief monitoring; avoid repeated dosing

Drug interactions

Itraconazole
Contraindicated
Database

Itraconazole inhibits CYP3A4 metabolism of oral midazolam and triazolam, leading to profound and prolonged sedation, respiratory depression, and psychomotor impairment. Effects can persist for days after itraconazole discontinuation due to long half-life.

CONTRAINDICATED. Avoid concurrent use. If benzodiazepine sedation is needed, consider lorazepam, oxazepam, or temazepam (glucuronidated, not CYP3A4-dependent) as alternatives. IV midazolam may be used with caution in monitored settings.

Source: Kimi deep-research + Cla

Sodium Oxybate
Contraindicated
Database

Profound CNS/respiratory depression

Do not combine

Source: Kimi deep-research + Cla

Azoles
Severe
Textbook

Increased plasma levels of midazolam.

Source: Harrison 22e · p1742

Methylnaltrexone
Severe
Textbook

Increased rates of accidental overdose and death.

Caution is advised, especially for patients with a history of drug abuse.

Source: G&G 14e

Nalmefene
Severe
Textbook

Increased rates of accidental overdose and death.

Caution is advised, especially for patients with a history of drug abuse.

Source: G&G 14e

Naloxone
Severe
Textbook

Increased rates of accidental overdose and death.

Caution is advised, especially for patients with a history of drug abuse.

Source: G&G 14e

Naltrexone
Severe
Textbook

Increased rates of accidental overdose and death.

Caution is advised, especially for patients with a history of drug abuse.

Source: G&G 14e

Amprenavir
Severe
Database

Drug interaction classified as: metabolism

Source: DDInter

Atazanavir
Severe
Database

Drug interaction classified as: metabolism

Source: DDInter

Boceprevir
Severe
Database

Drug interaction classified as: metabolism

Source: DDInter

Buprenorphine
Severe
Database

Increased rates of accidental overdose and death.

Caution is advised, especially for patients with a history of drug abuse.

Source: DDInter

Ceritinib
Severe
Database

Drug interaction classified as: metabolism

Source: DDInter

Related guidelines

Status epilepticus
AAN · Neurology · 2020
Induction of labour
FOGSI · Obstetrics & Gynaecology · 2019
Functional (psychogenic non-epileptic) seizures
AAN · Neurology · 2026
Initial monotherapy for newly diagnosed epilepsy
ILAE · Neurology · 2013
Primary PCI for acute coronary syndrome
ESC · Cardiology · 2026

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Sources: KD Tripathi 7e, Goodman & Gilman 14e, Harrison 22e, Katzung·Verified: 2026-05-19 · House clinical team·Cockpit curated: 2026-05-19